Since 1/1/23 BCBS Medical has been adding modifier 51 onto my 3rd molar claims for all 3 teeth after the first tooth line item and reducing my allowance as multiple procedure discount and/or bilateral procedure discount. I've spent many hours on the phone with people that can't give me an answer as to why this is all of a sudden happening when 3rds molars in different quadrants/sites have never been processed this way. Is anyone else having this issue and if so have you gotten it resolved? No other carriers are doing this.
We have not run into this yet since our local BCBS plan allows us to bill dental codes on medical forms. However my provider recently received an email from the president of AAOMS addressing this issue. Both AAOMS and the ADA are reaching out to CMS to address this issue in the future; in the meantime AAOMS has prepared sample appeal arguments and resources -- if your provider is an AAOMS member they should have access to these resources/samples.
Yes, we are experiencing this, as well. These are the the responses that we received from our local:
"The change in processing from 12/31/22 (in not applying multiple surgery) to 01/01/23 (now applying multiple surgery), is as a result in the change in CMS Federal Register Multiple Surgery indicator assignment. – our multiple policy rules and criteria has always followed the CMS Federal registry (unless otherwise noted in the contract). If/when CMS changes the code to being subjected to multiple surgery, or excluded from multiple surgery, we would follow suit and enforce accordingly. That is what has occurred here.
Also, as you may be aware, all reimbursement policies and changes to our amendments are published in Availity and now, after 03/01/2023, are available online for the provider to view on the Anthem.com website.
Prior to and up until 12/31/22: As captured on the left, the CMS Federal Registry file denotes D7240 as not subject to multiple surgery editing, by having a multiple procedure value as “0”- please note crosswalk value on the right, defining “0” as subject to “not subject to multiple surgery criteria.”
"While we understand the difficulties this new policy from CMS may cause, Anthem’s policy has always been to follow CMS guidelines. We cannot speak to the legitimacy of CMS’s decisions however, it may be helpful for you to reach out directly to CMS regarding this change. We have and will follow whatever guidelines CMS publishes. Since this is not an Anthem-driven policy, are you seeing other payers following the same CMS policy?"
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